Healthcare Provider Solutions

There is not much that is more frustrating than receiving a denial after submitting a chart to a reviewer, resolving the issue and then under appeal it is denied again for a different reason! Whether it is a pre-payment review or a post payment review it is all the same, in my mind, but evidently, not to CMS.

Once an agency has had a chart reviewed, under any level, there are appeal rights. The first level of appeal is reconsideration, which is sent to the Medicare Administrative Contractors (MAC) that handles your claims processing. If you need to file an additional appeal the process is referred to as redetermination and filed with the Qualified Independent Contractors (QIC). Generally, MACs and QICs have discretion while conducting appeals to develop new issues and review all aspects of coverage and payment related to a claim or line item. As a result, in some cases where the original denial reason is resolved, this expanded review of additional evidence or issues results in an unfavorable appeal decision for a different reason.

For redeterminations and reconsiderations of claims denied following a post-payment review or audit, CMS has instructed MACs and QICs to limit their review to the reason(s) the claim or line item at issue was initially denied. Post-payment review or audit refers to claims that were initially paid by Medicare and subsequently reopened and reviewed by, for example, a Zone Program Integrity Contractor (ZPIC), Recovery Auditor, MAC, or Comprehensive Error Rate Testing (CERT) contractor, and revised to deny coverage, change coding, or reduce payment. If an appeal involves a claim or line item denied on a pre-payment basis, MACs and QICs may continue to develop new issues and evidence at their discretion and may issue unfavorable decisions for reasons other than those specified in the initial determination.

This does offer some relief from additional denial reasons late in the appeal process for post-payment reviews, but not for pre-payment. The moral of the story: make sure your charts are Medicare compliant and pre-bill audits are conducted so that charts pass any reviews on the first level of review. The link below will provide the MLN Article:

SE1521.pdf